Male Urinary Tract (IPSS) Assessment Form

If you have been advised by the practice to submit a Male Urinary Tract (IPSS) review, please use this form.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Urinary Tract Review

    How often does your bladder not feel empty when finished passing urine?
    How often do you need to pass urine within 2 hours of last urinating?
    How often does the flow stop and start when passing urine?
    How often is it hard to delay passing urine?
    How often is the flow poor?
    How often do you need to push or strain to begin?
    How often do you need to pass urine after going to bed?
The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.
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Page last reviewed: 14 October 2026
Page created: 12 October 2026